Medicine & Surgery
Michael Murphy

Contents

Essential anatomy 5

Cardiac arrhythmias 5

Mechanisms of arrhythmia production 5

Heart block 6

Atrioventricular block 6

Bundle Branch Block 6

Supraventricular Tachycardias 7

Ventricular Tachycardias 7

Vaughn-Williams-Singh classification 7

Heart failure 8

Ischaemic Heart Disease 9

Angina Pectoris 9

Acute coronary Syndromes 9

Valvular Heart Disease 10

Infective Endocarditis 11

Congenital Heart Disease 12

Diseases of Heart Muscle 12

Acute Myocarditis 12

Hypertrophic Cardiomyopathy 13

Pericardial disease 13

Pericarditis 13

Pericardial effusion 13

Peripheral Vascular Disease 14

Disorders of the Pituitary 15

Hypopituitarism 15

Growth Failure 15

Short Stature 15

Acromegaly & Giantism 15

Hyperprolactinaemia 16

Thyroid Disease 16

Hypothyroidism 17

Hyperthyroidism 17

Grave’s Disease 17

Glucocorticoids 18

Addison’s disease – hypoadrenalism 19

Cushing’s Syndrome 19

Diabetes Insipidus 21

Syndrome of inappropriate ADH 21

Parathyroid Hormone 22

Primary Hyperparathyroidism 22

Hypertension & Endocrinology 23

Primary hyperaldosteronism 23

Phaeochromocytoma 23

Pharynx & Oesophagus 24

Structure & Function 24

Symptoms of oesophageal disorders 24

Signs 24

Investigations 24

Gastro-Oesophageal Reflux Disease (GORD) 24

Clinical features 25

Treatment 25

Complications 25

Achalasia 25

The Stomach 26

Helicobacter pylori 26

Results of infection 26

Peptic ulcer disease 27

Investigations of H pylori infection 27

Eradication therapy 27

Acute Upper GI Bleeding 27

Acute Lower GI Bleeding 29

Chronic GI Bleeding 29

The Small Intestine 29

Coeliac disease 29

Inflammatory Bowel Disease 30

Diverticular Disease 31

Colorectal cancer 31

Appendicitis 33

Acute peritonitis 33

Localised 33

Generalised 33

The Liver, Biliary Tract & Pancreatic Disease 34

Functions of the liver 34

Liver Disease 35

Jaundice 35

Haemolytic 35

Congenital hyperbilirubinaemias (non-haemolytic) 35

Cholestatic Jaundice (acquired) 36

Clinical features 36

Gallstones 38

Acute cholecystitis 38

Chronic cholecystitis 38

Biliary colic 38

Differential diagnosis 38

Pancreas 39

Acute pancreatitis 39

Chronic pancreatitis 40

Carcinoma of the pancreas 40

Haematological Disease 41

Anaemia 41

Clinical features 41

Types of anaemia 41

Microcytic anaemia 41

Normocytic anaemia 41

Macrocytic anaemia 42

Haemolytic anaemia 42

Corticospinal (pyramidal) system 43

Extrapyramidal system 43

Cerebellum 43

Stroke & Cerebrovascular Disease 44

Transient Ischaemic Attacks 44

Cerebral Infarct 44

Intracranial haemorrhage 45

Epilepsy 45

Parkinson’s disease 46

Multiple Sclerosis 46

Meningitis 47

Encephalitis 47

Motor Neurone Disease 48

Guillain-Barre Syndrome 48

Myasthenia Gravis 49

Duchenne muscular dystrophy 49

Headaches 50

Blackouts 50

Space occupying lesions 51

Raised ICP 51

COPD 52

Bronchiectasis 53

Cystic Fibrosis 53

Pneumonia 54

Sarcoidosis 55

Tumours 56

Bronchial Carcinoma 56

Pleural effusion 57

Pulmonary Embolism 57

Urinary tract infection 59

Glomerulonephritis 59

Nephrotic Syndrome 60

Acute renal failure 60

Chronic renal failure 60

Autosomal dominant polycystic kidney disease 61

Tumours of the Kidney & Genitourinary Tract 61

Disease of the Prostate Gland 61

Renal calculi 62

Medicine & Surgery

Cardiology

Essential anatomy

• Sinus node

  • Generates impulses automatically by spontaneous depolarisation of its membrane

  • Pacemaker

  • Influx of sodium controls the depolarisation

  • The rate of depolarisation is controlled by: autonomic tone, stretch, temp, hypoxia, pH

• Atrial & ventricular myocyte action potentials

  • Different to sinus node cells

  • Arrival of AP opens Na channels resulting in a fast depolarisation

Cardiac Cycle

Cardiac arrhythmias

Bradycardia<60bpm

Tachycardia>100bpm

• Supraventricular

• Ventricular

Sinus rhythm

Mechanisms of arrhythmia production

Sinus bradycardia – slow automacity

Bradycadia due to AV block – abnormal conduction in the AV node

• Accelerated automacity

  • Reducing the threshold potential

  • Increasing the rate of diastolic depolarization

• Triggered activity

  • Myocardial damage can lead to oscillations in the transmembrane potential

  • These ‘after depolarisations’ may reach the threshold and produce an arrhythmia

Sinus bradycardia

Heart block

Atrioventricular block

First-degree block

Prolonged PR interval by more than 0.22s

Second-degree block

Some p waves occur but others do not

• Mobitz I block (Wenckebach)

  • Progressive PR interval prolongation until P waves fail to conduct

• Mobitz II block

  • Every now and then, there is a dropped QRS

• 2:1or3:1

  • Where every second or third P wave conducts the ventricles

3^rd degree (complete) block

When all activity fails to conduct to the ventricles

No relationship between P waves and QRS complexes

P waves ~90/min QRS ~36/min

Bundle Branch Block

Normal PR interval

Widened QRS complex

RBBB

Late activation of the right ventricle

MARROW

LBBB

Late activation of the left ventricle

WILLIAM

Supraventricular Tachycardias

Arise from the atrium or the AV junction

QRS is of a normal shape

Atrial fibrillation

When individual muscle fibres contract on their own

No P waves, irregular QRS although a normal shape

Atrial flutter

Rater >250bpm

Saw-tooth P waves

Often an associated block ~3:1

Ventricular Tachycardias

Broad QRS

T waves difficult to identify

Regular QRS~200bpm

Ventricular fibrillation

No pattern

Patient is likely to lose consciousness

Vaughn-Williams-Singh classification

Class I – sodium channel blockers

Class II – competitive beta-blockers

Class III – potassium channel blockers

Class IV – calcium channel blockers

Heart failure

When the cardiac output is inadequate for the body’s requirements

25-50% 5-year prognosis

1-3% of the general population, ~10% of the elderly

Alveolar oedema

Kerley B lines

Cardiomegaly

Dilated prominent upper lobe vessels

New york classification of heart failure
I	Heart disease present, but no undue dyspnea from ordinary activity
II	Comfortable at rest, dyspnea on ordinary...

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